1
|
Kavelaars X, Mulder J, Kaptein M. Bayesian multilevel multivariate logistic regression for superiority decision-making under observable treatment heterogeneity. BMC Med Res Methodol 2023; 23:220. [PMID: 37798704 PMCID: PMC10552398 DOI: 10.1186/s12874-023-02034-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 09/11/2023] [Indexed: 10/07/2023] Open
Abstract
BACKGROUND In medical, social, and behavioral research we often encounter datasets with a multilevel structure and multiple correlated dependent variables. These data are frequently collected from a study population that distinguishes several subpopulations with different (i.e., heterogeneous) effects of an intervention. Despite the frequent occurrence of such data, methods to analyze them are less common and researchers often resort to either ignoring the multilevel and/or heterogeneous structure, analyzing only a single dependent variable, or a combination of these. These analysis strategies are suboptimal: Ignoring multilevel structures inflates Type I error rates, while neglecting the multivariate or heterogeneous structure masks detailed insights. METHODS To analyze such data comprehensively, the current paper presents a novel Bayesian multilevel multivariate logistic regression model. The clustered structure of multilevel data is taken into account, such that posterior inferences can be made with accurate error rates. Further, the model shares information between different subpopulations in the estimation of average and conditional average multivariate treatment effects. To facilitate interpretation, multivariate logistic regression parameters are transformed to posterior success probabilities and differences between them. RESULTS A numerical evaluation compared our framework to less comprehensive alternatives and highlighted the need to model the multilevel structure: Treatment comparisons based on the multilevel model had targeted Type I error rates, while single-level alternatives resulted in inflated Type I errors. Further, the multilevel model was more powerful than a single-level model when the number of clusters was higher. A re-analysis of the Third International Stroke Trial data illustrated how incorporating a multilevel structure, assessing treatment heterogeneity, and combining dependent variables contributed to an in-depth understanding of treatment effects. Further, we demonstrated how Bayes factors can aid in the selection of a suitable model. CONCLUSION The method is useful in prediction of treatment effects and decision-making within subpopulations from multiple clusters, while taking advantage of the size of the entire study sample and while properly incorporating the uncertainty in a principled probabilistic manner using the full posterior distribution.
Collapse
Affiliation(s)
- Xynthia Kavelaars
- Department of Methodology and Statistics, Tilburg University, Tilburg, The Netherlands.
- Department of Theory, Methodology, and Statistics, Open University of the Netherlands, Heerlen, The Netherlands.
| | - Joris Mulder
- Department of Methodology and Statistics, Tilburg University, Tilburg, The Netherlands
| | - Maurits Kaptein
- Jheronimus Academy of Data Science, Tilburg University, 's-Hertogenbosch, The Netherlands
| |
Collapse
|
2
|
Shiue K, Sahgal A, Lo SS. Precision Radiation for Brain Metastases With a Focus on Hypofractionated Stereotactic Radiosurgery. Semin Radiat Oncol 2023; 33:114-128. [PMID: 36990629 DOI: 10.1016/j.semradonc.2023.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
There are multiple published randomized controlled trials supporting single-fraction stereotactic radiosurgery (SF-SRS) for patients presenting with 1 to 4 brain metastases, with the benefit of minimizing radiation-induced neurocognitive sequelae as compared to whole brain radiotherapy . More recently, the dogma of SF-SRS as the only means of delivering an SRS treatment has been challenged by hypofractionated SRS (HF-SRS). The ability to deliver 25-35 Gy in 3-5 HF-SRS fractions is a direct consequence of the evolution of radiation technologies to allow image guidance, specialized treatment planning, robotic delivery and/or patient positioning corrections in all 6 degrees-of-freedom, and frameless head immobilization. The intent is to mitigate the potentially devastating complication of radiation necrosis and improve rates of local control for larger metastases. This narrative review provides an overview of outcomes specific to HF-SRS in addition to the more recent developments of staged SRS, preoperative SRS, and hippocampal avoidance-whole brain radiotherapy with simultaneous integrated boost.
Collapse
|
3
|
Ferini G, Viola A, Valenti V, Tripoli A, Molino L, Marchese VA, Illari SI, Rita Borzì G, Prestifilippo A, Umana GE, Martorana E, Mortellaro G, Ferrera G, Cacciola A, Lillo S, Pontoriero A, Pergolizzi S, Parisi S. Whole Brain Irradiation or Stereotactic RadioSurgery for five or more brain metastases (WHOBI-STER): A prospective comparative study of neurocognitive outcomes, level of autonomy in daily activities and quality of life. Clin Transl Radiat Oncol 2021; 32:52-58. [PMID: 34926839 PMCID: PMC8649107 DOI: 10.1016/j.ctro.2021.11.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 11/18/2021] [Accepted: 11/21/2021] [Indexed: 02/07/2023] Open
Abstract
The main aim of MBM treatment is to palliate neurological symptoms and to maintain an adequate QoL. SRT could be the “new standard” over WBI in the management of MBM patients. Neurocognitive functions could deteriorate more after WBI than after SRT.
Aims To evaluate neurocognitive performance, daily activity and quality of life (QoL), other than usual oncologic outcomes, among patients with brain metastasis ≥5 (MBM) from solid tumors treated with Stereotactic Brain Irradiation (SBI) or Whole Brain Irradiation (WBI). Methods This multicentric randomized controlled trial will involve the enrollment of 100 patients (50 for each arm) with MBM ≥ 5, age ≥ 18 years, Karnofsky Performance Status (KPS) ≥ 70, life expectancy > 3 months, known primary tumor, with controlled or controllable extracranial disease, baseline Montreal Cognitive Assessment (MoCA) score ≥ 20/30, Barthel Activities of Daily Living score ≥ 90/100, to be submitted to SBI by LINAC with monoisocentric technique and non-coplanar arcs (experimental arm) or to WBI (control arm). The primary endpoints are neurocognitive performance, QoL and autonomy in daily-life activities variations, the first one assessed by MoCa Score and Hopkins Verbal Learning Test-Revised, the second one through the EORTC QLQ-C15-PAL and QLQ-BN-20 questionnaires, the third one through the Barthel Index, respectively. The secondary endpoints are time to intracranial failure, overall survival, retreatment rate, acute and late toxicities, changing of KPS. It will be considered significant a statistical difference of at least 30% between the two arms (statistical power of 80% with a significance level of 95%). Discussion Several studies debate what is the decisive factor accountable for the development of neurocognitive decay among patients undergoing brain irradiation for MBM: radiation effect on clinically healthy brain tissue or intracranial tumor burden? The answer to this question may come from the recent technological advancement that allows, in a context of a significant time saving, improved patient comfort and minimizing radiation dose to off-target brain, a selective treatment of MBM simultaneously, otherwise attackable only by WBI. The achievement of a local control rate comparable to that obtained with WBI remains the fundamental prerequisite. Trial registration NCT number: NCT04891471.
Collapse
Key Words
- 3D-CRT, 3Dimensional-ConformalRadioTherapy
- Autonomy in daily activities
- BSC, Best Supportive Care
- Brain metastases
- CRF, Case Report Form
- CT, Computerized Tomography
- CTV, Clinical Target Volume
- EORTC QLQ-C15-PAL, European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 15 for Palliative Care
- FSRT, Fractionated Stereotactic Radiation Therapy
- GTV, Gross Tumor Volume
- KPS, Karnofsky Performance Status
- LINAC, Linear Accelerator
- MBM, Multiple Brain Metastastes
- MRI, Magnetic Resonance Imaging
- MoCA, Montreal Cognitive Assessment
- NCCN, National Comprehensive Cancer Network
- Neurocognitive decay
- Neurocognitive performance
- Neurocognitive tests
- OAR, Organ At Risk
- OS, Overall Survival
- PTV, Planning Target Volume
- Palliative care
- QLQ-BN20, Quality of Life Questionnaire - Brain Neoplasm 20
- QoL, Quality of Life
- Quality of life
- RT, Radiation Therapy
- RTOG, Radiation Therapy Oncology Group
- Radiotherapy for multiple brain metastases
- SBI, Stereotactic Brain Irradiation
- SRS, Stereotactic RadioSurgery
- SRT, Stereotactic Radiation Therapy
- Stereotactic Brain RadioSurgery
- Stereotactic Brain Radiotherapy
- Supportive care in cancer patients
- VEGF, Vascular Endothelial Growth Factor
- Whole Brain Radiotherapy
Collapse
Affiliation(s)
| | - Anna Viola
- Fondazione IOM, Viagrande, I-95029 Catania, Italy
| | - Vito Valenti
- REM Radioterapia srl, Viagrande, I-95029 Catania, Italy
| | | | - Laura Molino
- Dipartimento di Scienze Biomediche, Odontoiatriche e delle Immagini Morfologiche e Funzionali Università di Messina, I-98100 Messina, Italy
| | | | | | | | - Angela Prestifilippo
- Medical Oncology Unit, Mediterranean Institute of Oncology, Viagrande, I-95029 Catania, Italy
| | - Giuseppe Emmanuele Umana
- Trauma Center, Gamma Knife Center, Department of Neurosurgery, Cannizzaro Hospital, I-95125 Catania, Italy
| | | | - Gianluca Mortellaro
- Department of Radiation Oncology, ARNAS Ospedale Civico, I-90127 Palermo, Italy
| | - Giuseppe Ferrera
- Department of Radiation Oncology, ARNAS Ospedale Civico, I-90127 Palermo, Italy
| | - Alberto Cacciola
- Dipartimento di Scienze Biomediche, Odontoiatriche e delle Immagini Morfologiche e Funzionali Università di Messina, I-98100 Messina, Italy
| | - Sara Lillo
- Dipartimento di Scienze Biomediche, Odontoiatriche e delle Immagini Morfologiche e Funzionali Università di Messina, I-98100 Messina, Italy
| | - Antonio Pontoriero
- Dipartimento di Scienze Biomediche, Odontoiatriche e delle Immagini Morfologiche e Funzionali Università di Messina, I-98100 Messina, Italy
| | - Stefano Pergolizzi
- Dipartimento di Scienze Biomediche, Odontoiatriche e delle Immagini Morfologiche e Funzionali Università di Messina, I-98100 Messina, Italy
| | - Silvana Parisi
- Dipartimento di Scienze Biomediche, Odontoiatriche e delle Immagini Morfologiche e Funzionali Università di Messina, I-98100 Messina, Italy
| |
Collapse
|
4
|
Park SJ, Lim SH, Kim YJ, Moon KS, Kim IY, Jung S, Kim SK, Oh IJ, Hong JH, Jung TY. The Tumor Control According to Radiation Dose of Gamma Knife Radiosurgery for Small and Medium-Sized Brain Metastases from Non-Small Cell Lung Cancer. J Korean Neurosurg Soc 2021; 64:983-994. [PMID: 34689476 PMCID: PMC8590918 DOI: 10.3340/jkns.2021.0165] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 09/07/2021] [Indexed: 11/27/2022] Open
Abstract
Objective The effectiveness of gamma knife radiosurgery (GKR) in the treatment of brain metastases is well established. The aim of this study was to evaluate the efficacy and safety of maximizing the radiation dose in GKR and the factors influencing tumor control in cases of small and medium-sized brain metastases from non-small cell lung cancer (NSCLC).
Methods We analyzed 230 metastatic brain tumors less than 5 mL in volume in 146 patients with NSCLC who underwent GKR. The patients had no previous radiation therapy for brain metastases. The pathologies of the tumors were adenocarcinoma (n=207), squamous cell carcinoma (n=18), and others (n=5). The radiation doses were classified as 18, 20, 22, and 24 Gy, and based on the tumor volume, the tumors were categorized as follows : small-sized (less than 1 mL) and medium-sized (1–3 and 3–5 mL). The progression-free survival (PFS) of the individual 230 tumors and 146 brain metastases was evaluated after GKR depending on the pathology, Eastern Cooperative Oncology Group (ECOG) performance score (PS), tumor volume, radiation dose, and anti-cancer regimens. The radiotoxicity after GKR was also evaluated.
Results After GKR, the restricted mean PFS of individual 230 tumors at 24 months was 15.6 months (14.0–17.1). In small-sized tumors, as the dose of radiation increased, the tumor control rates tended to increase (p=0.072). In medium-sized tumors, there was no statistically difference in PFS with an increase of radiation dose (p=0.783). On univariate analyses, a statistically significant increase in PFS was associated with adenocarcinomas (p=0.001), tumors with ECOG PS 0 (p=0.005), small-sized tumors (p=0.003), radiation dose of 24 Gy (p=0.014), synchronous lesions (p=0.002), and targeted therapy (p=0.004). On multivariate analyses, an improved PFS was seen with targeted therapy (hazard ratio, 0.356; 95% confidence interval, 0.150–0.842; p=0.019). After GKR, the restricted mean PFS of brain at 24 months was 9.8 months (8.5–11.1) in 146 patients, and the pattern of recurrence was mostly distant within the brain (66.4%). The small and medium-sized tumors treated with GKR showed radiotoxicitiy in five out of 230 tumors (2.2%), which were controlled with medical treatment.
Conclusion The small-sized tumors were effectively controlled without symptomatic radiation necrosis as the radiation dose was increased up to 24 Gy. The medium-sized tumors showed potential for symptomatic radiation necrosis without signifcant tumor control rate, when greater than 18 Gy. GKR combined targeted therapy improved the tumor control of GKR-treated tumors.
Collapse
Affiliation(s)
- Sue Jee Park
- Department of Neurosurgery, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Sa-Hoe Lim
- Department of Neurosurgery, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Young-Jin Kim
- Department of Neurosurgery, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Kyung-Sub Moon
- Department of Neurosurgery, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - In-Young Kim
- Department of Neurosurgery, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Shin Jung
- Department of Neurosurgery, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Seul-Kee Kim
- Department of Radiology, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - In-Jae Oh
- Department of Internal Medicine, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Jong-Hwan Hong
- Department of Neurosurgery, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Tae-Young Jung
- Department of Neurosurgery, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| |
Collapse
|
5
|
van Grinsven EE, Nagtegaal SHJ, Verhoeff JJC, van Zandvoort MJE. The Impact of Stereotactic or Whole Brain Radiotherapy on Neurocognitive Functioning in Adult Patients with Brain Metastases: A Systematic Review and Meta-Analysis. Oncol Res Treat 2021; 44:622-636. [PMID: 34482312 DOI: 10.1159/000518848] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 07/31/2021] [Indexed: 11/19/2022]
Abstract
Background & Objectives: Radiotherapy is standard treatment for patients with brain metastases (BMs), although it may lead to radiation-induced cognitive impairment. This review explores the impact of whole-brain radiotherapy (WBRT) or stereotactic radiosurgery (SRS) on cognition. METHODS The PRISMA guidelines were used to identify articles on PubMed and EmBase reporting on objective assessment of cognition before, and at least once after radiotherapy, in adult patients with nonresected BMs. RESULTS Of the 867 records screened, twenty articles (14 unique studies) were included. WBRT lead to decline in cognitive performance, which stabilized or returned to baseline in patients with survival of at least 9-15 months. For SRS, a decline in cognitive performance was sometimes observed shortly after treatment, but the majority of patients returned to or remained at baseline until a year after treatment. CONCLUSIONS These findings suggest that after WBRT, patients can experience deterioration over a longer period of time. The cognitive side effects of SRS are transient. Therefore, this review advices to choose SRS as this will result in lowest risks for cognitive adverse side effects, irrespective of predicted survival. In an already cognitively vulnerable patient population with limited survival, this information can be used in communicating risks and aid in making educated decisions.
Collapse
Affiliation(s)
- Eva Elisabeth van Grinsven
- Department of Neurology & Neurosurgery, University Medical Center Utrecht Brain Center, Utrecht University, Utrecht, The Netherlands
| | - Steven H J Nagtegaal
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Joost J C Verhoeff
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Martine J E van Zandvoort
- Department of Neurology & Neurosurgery, University Medical Center Utrecht Brain Center, Utrecht University, Utrecht, The Netherlands.,Department of Experimental Psychology and Helmholtz Institute, Utrecht University, Utrecht, The Netherlands
| |
Collapse
|
6
|
Kavelaars X, Mulder J, Kaptein M. Decision-making with multiple correlated binary outcomes in clinical trials. Stat Methods Med Res 2020; 29:3265-3277. [PMID: 32672498 PMCID: PMC7682528 DOI: 10.1177/0962280220922256] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Clinical trials often evaluate multiple outcome variables to form a comprehensive picture of the effects of a new treatment. The resulting multidimensional insight contributes to clinically relevant and efficient decision-making about treatment superiority. Common statistical procedures to make these superiority decisions with multiple outcomes have two important shortcomings, however: (1) Outcome variables are often modeled individually, and consequently fail to consider the relation between outcomes; and (2) superiority is often defined as a relevant difference on a single, on any, or on all outcome(s); and lacks a compensatory mechanism that allows large positive effects on one or multiple outcome(s) to outweigh small negative effects on other outcomes. To address these shortcomings, this paper proposes (1) a Bayesian model for the analysis of correlated binary outcomes based on the multivariate Bernoulli distribution; and (2) a flexible decision criterion with a compensatory mechanism that captures the relative importance of the outcomes. A simulation study demonstrates that efficient and unbiased decisions can be made while Type I error rates are properly controlled. The performance of the framework is illustrated for (1) fixed, group sequential, and adaptive designs; and (2) non-informative and informative prior distributions.
Collapse
Affiliation(s)
- Xynthia Kavelaars
- Department of Methodology and Statistics, Tilburg University, Tilburg, The Netherlands
| | - Joris Mulder
- Department of Methodology and Statistics, Tilburg University, Tilburg, The Netherlands.,Jheronimus Academy of Data Science, 's-Hertogenbosch, The Netherlands
| | - Maurits Kaptein
- Jheronimus Academy of Data Science, 's-Hertogenbosch, The Netherlands
| |
Collapse
|
7
|
Hewins W, Zienius K, Rogers JL, Kerrigan S, Bernstein M, Grant R. The Effects of Brain Tumours upon Medical Decision-Making Capacity. Curr Oncol Rep 2019; 21:55. [PMID: 31049786 PMCID: PMC6495430 DOI: 10.1007/s11912-019-0793-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Purpose of Review Informed consent is the integral part of good medical practice in patients with brain tumours. Capacity to consent may be affected by the brain disorder or its treatment. We intend to draw upon the current neuro-oncology literature to discuss the influence intracranial tumours have upon patients’ capacity to consent to treatment and research. Recent Findings We performed a systematic review of studies of capacity to consent for treatment or research in patients with intracranial tumours. The search retrieved 1597 papers of which 8 were considered eligible for review. Summary Although there are obvious inherent limitations to solely assessing cognition, most research consistently demonstrated increased risk of incapacity in brain tumour patients with cognitive impairment. Specific items in cognitive screening batteries, for example Semantic Verbal Fluency Test (SVFT), Hopkins Verbal Learning Test (HVLT-Recall), and Trail Making Test A/B (TMT), are simple, easily applied tests that may act as significant red flags to identify patients at increased risk of incapacity and who subsequently will require additional cognitive/psychiatric evaluation or more formal tests for capacity to consent for treatment or research.
Collapse
Affiliation(s)
- Will Hewins
- Department of Clinical Neurosciences, Western General Hospital, Edinburgh, EH4 2XU, Scotland.,Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, EH16 4SB, UK
| | - Karolis Zienius
- Department of Clinical Neurosciences, Western General Hospital, Edinburgh, EH4 2XU, Scotland
| | | | - Simon Kerrigan
- Department of Neurology, Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD, UK
| | - Mark Bernstein
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Canada
| | - Robin Grant
- Department of Clinical Neurosciences, Western General Hospital, Edinburgh, EH4 2XU, Scotland. .,Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, EH16 4SB, UK.
| |
Collapse
|
8
|
Nieder C, Yobuta R, Mannsåker B. Patterns of Treatment and Outcome in Patients With 20 or More Brain Metastases. In Vivo 2019; 33:173-176. [PMID: 30587619 DOI: 10.21873/invivo.11455] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 11/12/2018] [Accepted: 11/15/2018] [Indexed: 01/12/2023]
Abstract
BACKGROUND/AIM The aim of this study was to analyze the patterns of treatment and outcomes in patients with a large number of brain metastases, arbitrarily defined as 20 or more lesions. These patients are typically excluded from studies of focal brain treatment, e.g., surgery or radiosurgery, and might have a limited prognosis. PATIENTS AND METHODS This was a retrospective single-institution analysis. Overall, 11 patients were identified from a prospectively maintained database. RESULTS Ten patients had received active treatment (9 whole-brain radiotherapy, 7 systemic therapy). Median survival was 5.0 months without long-term survival beyond 13 months. Patients with better performance status had numerically longer survival, however we did not identify baseline parameters with a significant impact on survival. CONCLUSION While long-term survival was not observed in this small study, most patients survived long enough to experience symptomatic improvement from whole-brain radiotherapy. Therefore, we recommend multidisciplinary assessment of the patients' prognosis and systemic treatment options, and initiation of whole-brain radiotherapy if survival is not limited to 1-2 months.
Collapse
Affiliation(s)
- Carsten Nieder
- Department of Oncology and Palliative Medicine, Nordland Hospital, Bodø, Norway .,Department of Clinical Medicine, Faculty of Health Sciences, UiT - The Arctic University of Norway, Tromsø, Norway
| | - Rosalba Yobuta
- Department of Oncology and Palliative Medicine, Nordland Hospital, Bodø, Norway
| | - Bård Mannsåker
- Department of Oncology and Palliative Medicine, Nordland Hospital, Bodø, Norway
| |
Collapse
|
9
|
Turkaj A, Morelli AM, Vavalà T, Novello S. Management of Leptomeningeal Metastases in Non-oncogene Addicted Non-small Cell Lung Cancer. Front Oncol 2018; 8:278. [PMID: 30140655 PMCID: PMC6094962 DOI: 10.3389/fonc.2018.00278] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 07/04/2018] [Indexed: 12/13/2022] Open
Abstract
Brain metastases in non-small cell lung cancer (NSCLC) patients are more often detected due to imaging modalities improvements but also emerge because of improved treatments of the primary tumor which lead to a longer survival. In this context, development of leptomeningeal metastases (LM) is a devastating complication and its prognosis remains poor despite advances in systemic and local approaches. Histology characterization of NSCLC and molecular expression influence LM management. For those with “oncogene addiction,” new generation epidermal growth factor receptor (EGFR) and anaplastic lymphoma kinase (ALK) tyrosine kinase inhibitors (TKIs) were developed to strongly penetrate the blood-brain barrier (BBB) with the aim to prevent central nervous system cancer dissemination, eventually impacting on LM appearance and its subsequent management. Systemic chemotherapy, often combined with intrathecal chemotherapy (when possible), was one of common indications for lung cancer patients affected by LM, without driver mutations and a good performance status but currently, with the advent of innovative systemic approaches treatment solutions in this subgroup of patients are rapidly evolving. Whole brain radiation therapy (WBRT) is the conventional treatment for patients with brain metastases. Furthermore, modern radiation techniques, as stereotactic radiotherapy (SRT), improve outcomes in those cases with a limited number of lesions. However, LM represent a minority of CNS metastases and few literature data are available to drive the radiotherapy approach. Considering all relevant progress made in this setting, after a literature review, the aim of this paper is to discuss about recent developments and therapeutic options in LM management of non-oncogene addicted NSCLC.
Collapse
Affiliation(s)
- Ana Turkaj
- Department of Oncology, University of Torino, Ospedale San Luigi Gonzaga, Orbassano, Italy
| | - Anna M Morelli
- Department of Oncology, University of Torino, Ospedale San Luigi Gonzaga, Orbassano, Italy
| | - Tiziana Vavalà
- SC of Oncology, ASL CN1, Ospedale Civile di Saluzzo, Saluzzo, Italy
| | - Silvia Novello
- Department of Oncology, University of Torino, Ospedale San Luigi Gonzaga, Orbassano, Italy
| |
Collapse
|